What inspires four jobbing GPs to stand up at an RCGP conference and discuss their working lives by possibly the least favoured method of communication, Powerpoint?
We were grateful to be given the opportunity to talk to our colleagues about working at the ‘Deep End’, the 100 most-deprived practices in Scotland. Many of the stories that our patients tell us motivate us to keep working there, but individual enthusiasm for working in areas of high deprivation is not enough to prevent professional burn-out. We have therefore set up a working group to give ourselves the opportunity to reflect collectively upon the challenges that our patients face as they negotiate poverty and inequality, and the challenges that we face in our work with them.
My presentation to the RCGP focused on vulnerable children and families and the importance of a strong GP voice in the development and implementation of policies for child health and well-being.
‘Vulnerability’ is a broad construct and a metaphor for failings on many different levels from the caregiver-child relationship through to state systems. In this country we have a strong tradition of inheriting poverty.
For example, many children today live in families that cannot afford their food bills and are reliant on food distribution centres for their meals. Charities are picking up the gauntlet of providing for the destitute. These are Dickensian times indeed, but this is a breach of the universal children’s rights agenda that our government is signed up to.
Rather than expressing angst and wringing our hands in despair, working at Deep End practices gives us an opportunity to challenge a punitive political agenda that appears to be more focused upon maintaining ideological out-groups than tackling the perpetual effects of unjust social structures.
Dr Catriona Morton, a GP in a Lothian Deep End practice, presented her shared care antenatal clinic. Most GPs in Glasgow can only marvel at this work because our involvement in antenatal care has become virtually irrelevant.
Antenatal clinics that are run in general practice jointly with midwives and a visiting obstetrician seem almost revolutionary. Antenatal patients in deprived areas, who are often hard to reach and have higher morbidity and mortality rates, and ultimately poorer neonatal outcomes, would call her clinic the gold standard, but Dr Morton’s work is under threat because of funding issues.
Dr Morton produced national maternal outcome data and linked these with an audit of her own clinic. Filtering robust measurement outcomes (usually viewed by the academic community through the everyday working of Deep End practices) makes these data come alive. They show the adverse health effects of deprivation that we observe over years of practice. The dialogue between positivist research methods and the qualitative aspects of general practice working is bridged by the Deep End and we strive to maintain this discussion.
Dr Douglas Rigg is a GP in Glasgow at the most deprived practice in Scotland. His talk focused on the ‘unworried unwell’. All GPs will recognise this category of patient whom I suspect does not exclusively reside in the Deep End, but the sheer numbers of the ‘unworried unwell’ require particular strategies to intervene and improve their poor outcomes.
He gave exemplars of those who not only avoid health contacts but have no inkling that they may need healthcare interventions.
Are they fatalistic, self-neglecting or self-destructive? Clearly, we don’t believe that any answer to the complexity of human behaviour is simplistic but we do advocate spending more time with patients who typically become sicker earlier and die younger than other patients. Many will start life as vulnerable children with patterns of poor health in childhood that stalk them into adulthood, with them never reaching their ‘economic potential’.
Despite our presentations covering very different clinical areas, they share a common thread across the age groups: the impact of poverty on an individual’s health, however old. The inequalities gap continues to widen in this country and the re-emergence and normalisation of destitution are very worrying, given the proposed further cuts to the welfare budget. The Deep End will continue to highlight this concern and engage across a spectrum of domains where we want to make a difference.
Dr Anne Mullin is a GP in Glasgow, and part of the Deep End project